J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.15.4.227 on 1 November 1952. Downloaded from http://jnnp.bmj.com/ on August 5, 2022 by guest.

J. Neurol. Neurosurg. Psychiat., 1952, 15, 227.

THORACIC INTERVERTEBRAL DISC PROLAPSE WITH

SPINAL CORD COMPRESSION
BY
VALENTINE LOGUE
Fronm the Neurosurgical Departments of St. George's Hospital, Lonidoni,
and the Maida Vale Hlospitalfor Nervous Diseases, Londonz

The serious disorders of nervous function which prolapses as reckoned by Love and Kiefer (1950)
may result from central protrusions of the inter- in the cases at the Mayo Clinic. It is of interest
vertebral disc are exemplified in the thoracic region that among these 250 cases there were also 14
of the spine where this type of prolapse has acquired patients with central lumbar disc protrusions
-a sinister reputation, and the few cases treated by producing cauda equina compression and 15 central
operation that have so far been reported bear cervical protrusions with spinal cord involvement.
witness to the severe damage that these protrusions
inflict on the spinal cord and to the grave hazards Site
attending their surgical removal. Thus, of Muller's There are 12 thoracic intervertebral discs, the
(1951) four cases, three were left after operation first lying between the first and second thoracic
with a complete or almost complete transection of vertebrae and the twelfth between the last thoracic

Protected by copyright.
the cord, and the fourth after a slight temporary and first lumbar vertebrae, and the portion of the
improvement also developed a total paraplegia. spinal cord which is exposed to compression by
Of Hawk's (1936) three patients who survived central protrusions of these discs extends from the
operation, all with severe pre-operative spinal cord third thoracic to the fifth lumbar spinal segment.
damage, one was made worse by, and the other Fig. 1 shows the disc levels at which the protrusions
two showed no benefit from, surgery. Mixter and
Barr (1934) reported three cases, two of which
developed a total transverse lesion and the third
eventually showed slight improvement. So of
10 cases of central thoracic disc prolapse treated
surgically, six were left with virtually complete cord
transection and there was little or no worthwhile
improvement in the other four, a unique morbidity
rate among benign compression lesions of the cord.
It is my purpose to describe a series of 11 cases
all proven by operation which does to some extent
confirm this grave picture, but also reveals that it is
possible to make an accurate pre-operative diagnosis
of this type of hemiation and to remove a certain
number of these protruding discs not only without
further damage to the spinal cord but with almost
complete restitution of neurological function.
Incidence
These 11 cases have appeared in a modest total of
250 disc protrusions at all levels, an incidence of FIG. I.-The figures on the left refer to the 11 cases in this series.
4%h for thoracic prolapse, which is a greatly exag- The list of 43 on the right includes an additional 32 reported
gerated one owing to the restricted choice of cases cases: Bradford and Spurling (1945) one; Elsberg (1931) two;
Hawk (1936) four; Love and Kiefer (1950) 17, including three
for admission; the true proportion is probably in of lateral disc protrusion; Mixter and Barr (1934) four cases;
the neighbourhood of two or three per 1,000 disc and Muller (1951) four cases.
227
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228 VALENTINE LOGUE
have occurred. The list on the left of the diagram histories at the end of this paper. A study of them
refers to this series of 11 cases. To obtain a more confirms what might have been expected; that
accurate picture an additional 32 reported cases, there are no symptoms or signs which are charac-
verified by operation or necropsy, have been teristic of compression of the spinal cord by a
collected making a combined total of 43, which is thoracic disc prolapse and that they do not differ
shown in the list to the right of the diagram. This materially from those produced by spinal neo-
demonstrates that central protrusions are confined plasms. The following case illustrates some of the
to the lower nine intervertebral discs without, common clinical features of the condition and also
however, a predilection for any two of them as the pitfalls that may beset the diagnosis in the early
pertains in the lumbar and cervical regions. stages.
Sex, Age, and Trauma Case 11.-A man aged 45, a research chemist, seven
months before admission developed pain in his back
Table I shows that there are nine men and two at about the dorsi-lumbar junction, slightly to the left
women in the series, in accord with the general rule of the midline. It was intermittent, had an aching
that disc protrusions at any level tend to be more character, and was made worse when lying down, but
common in males. This predominance is confirmed, was unaffected by coughing and straining. He had
but on a lesser scale, by the larger group of 43 cases sustained no injury to his spine.
in which the ratio is as five to three. It is also A few days later numbness appeared in the right thigh
apparent from this table that thoracic disc prolapse and quickly spread down the leg to the toes and
is a disease of middle and late adult life, the youngest upwards to the level of the umbilicus. Two weeks
later the right leg became stiff, weak, and unreliable
patient being 38 years old and the average age of so that he tended to fall. He was investigated at another
the whole series 50 years. hospital two months after the onset of symptoms and
was found to have a spastic right leg with increased
TABLE I reflexes in both legs and a right extensor plantar response.

Protected by copyright.
SEX, AGE, AND INCIDENCE OF TRAUMA IN 11 CASES There was patchy impairment of sensation to pain and
light touch over the right leg and the inner side of the
Case SxAe
Sex Age History of left ankle. Lumbar puncture at that time showed
No. Trauma
no evidence of spinal block and the fluid contained
1 Male 48 Yes three cells and 25 mg. % of protein. He was thought to
2 Male 44 No
3 Male 38 Yes be suffering from atypical disseminated sclerosis and
4 Male 52 No was sent home. His symptoms progressed steadily
5 Male 62 No
6 Female 44 No and five months after the onset weakness and numbness
7 Female 63 Yes appeared in the left leg and he also developed urgency
8 Male 54 No
9 Male 61 No of micturition and difficulty in defaecation.
10 Male 44 No
11 Male 45 No
Neurological Examination.-There was a little weak-
ness in the lower abdominal muscles and considerable
Direct or indirect trauma plays little part in the weakness of both legs with increased tone, more marked
aetiology of prolapse in this region of the spine. on the right, and sustained ankle clonus. Coordination
In only three of these patients was there any possible was grossly impaired.
The abdominal reflexes were absent. The knee and
association with injury. In one patient (Case 1) ankle jerks were exaggerated, more so on the right.
the first symptom of back pain, which preceded the Both plantar responses were extensor.
onset of neurological signs by 10 years, appeared There was a level at the seventh thoracic dermatome
while he was lifting some heavy weights. In the on both sides below which there was some impairment
second (Case 3) back pain appeared a few days after of pain sense and a more definite level at the tenth
an episode of vigorous gardening and was followed dermatome below which there was considerable impair-
five months later by cord compression. The third ment to pain, light touch, and temperature, but not
patient (Case 7) twisted her back while turning complete loss. Position sense was absent at the toes
suddenly and her first symptoms appeared next day. and reduced at the ankles. Vibration sense was absent
In the remaining eight cases there was no history over the right tibia and reduced on the left.
He was just able to walk without support, but very
of injury or unusual exertion and the patients were unsteadily on a wide base.
otherwise in normal health. He was later proved to have a prolapse from the
ninth-tenth intervertebral -disc. (The details of investiga-
Clinical Features tion are described at the end of this paper.)
A description the neurological findings in each
of In general the symptoms of cord compression
of these patients appears in some detail in the case appeared in the chronological order of sensory

THORACIC DISC PROLAPSE WITH SPINAL CORD COMPRESSION
(pain, tingling, burning, coldness, or numbness),
motor, and sphincter, and once begun the course
was that of a relentless and fairly rapid progression
so that in eight of the 11 cases the time elapsing
from the first symptom of compression to the
development of a marked neurological deficit
warranting surgery was less than seven months.
As exceptions to this rule there were three cases
(Nos. 6, 4, and 7) with histories of 14 months, two
years, and 10 years respectively, and in the last of
these the course did show some remittent features.
Among the first group of eight cases there were
three (Cases 5, 8, 9), and these will be referred to
again when dealing with the mechanics of com-
pression, in which the symptoms of a severe para-
plegia developed acutely in the course of several
days, but in only one (Case 9) was a recent soft disc
prolapse found at operation. In the other two
cases the protrusion was bony hard and had
obviously been present for a considerable time,
probably years, and the sudden appearance of a
paraplegia was thought to be due to interference
with the blood supply to the cord.
In most of the patients the symptoms started in
both legs at the same time, or if they did appear
first in one leg the other was soon involved, so that
by the time of admission to hospital neurological
examination revealed signs indicative of com-
pression of both halves of the spinal cord. In
three patients, however (Cases 1, 2, 3), the presenting
neurological picture was that of a Brown-Sequard
syndrome, resulting from compression of one half
of the spinal cord by a prolapse situated just to one
side of the midline of the spinal canal. That pro-
truded cervical discs could cause either bilateral or
strictly unilateral cord compression was noted some
years ago by Stookey (1928) and in practice this
distinction is not as artificial as it may at first
appear. This observation of Stookey's also holds
true for the thoracic region, but here the hemi-
compression syndromes are proportionately less
frequent and not so clearly defined as with cervical
protrusions because of the larger size of the thoracic
prolapse relative to the smaller bulk of the spinal
cord in this region. In the three representative
cases mentioned above the syndromes are by no
means complete.
In the sensory field, as would be expected with an
anteriorly situated lesion, pain and temperature
sense were more affected than light touch and the
modalities subserved by the posterior columns; in
fact in some cases the latter structures were practi-
cally uninvolved.
One patient (Case 11) showed sensory impairment
extending up to a dermatome level considerably
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229
higher (four segments) than that of the spinal
segment actually under compression and gave rise
to some confusion in localization. This phenomenon
has been previously noted in thoracic prolapse
(Hawk, 1936) and is of course well recognized,
although not satisfactorily explained, in association
with spinal neoplasm and in cervical disc prolapse.
Sphincter disturbance was not a prominent
symptom and, except for one case, when it did
occur it appeared late in the course of the com-
pression. In six patients there were no bladder or
rectal disturbances whatsoever, often despite severe
weakness of the legs. In three cases there was mild
urgency or dribbling on micturition, and in only
two cases, both with gross paraplegia, was there loss
of sphincter control (Cases 7 and 10).
Pain
A feature of central disc prolapse which is
common to the cervical and thoracic regions is the
inconstant association of pain, either local or
radicular. In nearly half of these cases (five out of
11) there was no complaint of pain at any time in
the evolution of the clinical picture. Of the six
Protected by copyright.
patients who did experience pain, four (Cases 1, 3,
9, and 11) felt it locally in the back, where it prece1ed
the onset of cord symptoms by a variable time
ranging in the individual case from a few hours to
10 years. The pain was felt in the midline of the
spine, sometimes extending a little to one side, and
was located in the upper lumbar or thoraco-lumbar
regions irrespective of the level of the prolapse.
It was usually described as having an aching
character, was not particularly severe, and often
occurred in attacks similar to lumbar disc pain.
In the remaining two patients (Cases 5 and 8) the
prolapse was at the D.12/L.1 level and nerve root
pain was produced which had a characteristic
distribution extending from the upper lumbar
region down the front and back of each lower limb
as far as the ankle, but predominating in the anterior
aspect of the thighs. This radiation was explained
by the location of the prolapse where it was anato-
mically possible for it to involve the majority of the
lumbar and also the upper sacral nerve roots as
they lie closely grouped together round the conus
medullaris.
Investigations
Changes in the Cerebrospinal Fluid.-Table 11
illustrates the degree of block on manometry and
the protein content of the cerebrospinal fluid in the
11 cases. Five of the patients had a complete or
almost complete spinal manometric block with, in
the four cases in which it was recorded, considerable
 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.15.4.227 on 1 November 1952. Downloaded from http://jnnp.bmj.com/ on August 5, 2022 by guest.
230 VALENTINE LOGUE
TABLE II Of these 11 cases of thoracic prolapse, no less than
MANOMETRIC CHANGES AND PROTEIN CONTENT OF eight showed unequivocal calcification in a nucleus
CEREBROSPINAL FLUID pulposus. The significance of this finding was
brought out by a study of the radiographs of the
Case Manometric Protein Content of C.S.F. thoracic spine of 100 cases of similar age group
No. Results (mg. per 100 ml.)
55
who had had radiographs taken because of local
I No block
2 No block Not recorded spinal symptoms resulting from injury, arthritis,
3 Partial block 30 etc., and in which nuclear calcification was observed
4 Complete block Yellow fluid; protein
content not recorded in only four instances compared with an incidence
5 Complete block Yellow fluid 175
6 Complete block 95 of over 70% with disc prolapse.
7 Complete block 150 Again, in 25 patients suffering from thoracic
8 Almost complete block 200
9 Partial block
Partial block
100
20
spinal compression by neoplasms such as neuro-
10
11 No block 50 fibromata, meningiomata, and metastasic tumours,
drawn from a similar age group, there were no
elevation of the protein content of the cerebrospinal instances of nuclear calcification.
fluid to 200, 175, 150, and 95 mg. per 100 ml. The calcified disc, however, is not necessarily
respectively. A partial block or "sticky" mano- strictly related to the level of the prolapse. Table III
metrics was recorded in three patients (Cases 9, 3, III
and 10) with a protein content of 100, 20, and 30 mg. INTERVERTEBRAL DISCTABLE LEVEL OF CALCIFICATION,
per 100 ml. In the remaining three cases there RELATIONSHIP TO THE SITE OF PROLAPSE, AND MYELO-
was no evidence of block and the cerebrospinal GRAPHIC APPEARANCES
fluid protein was 55 and 50 mg. per 100 ml. Level of Myelographic
Level of Disc
respectively in the two cases in which it was recorded. Case No. Prolapse Calcification Appearances
It should also be noted that in two of the patients 1 D 9/10 D 9/10 Oval defect 2 x 1-5 cm.

Protected by copyright.
(Cases 4 and 11) both the cerebrospinal fluid and 2 D 8/9
D 8/9
D 8/9
D 8/9and9/10
Partial block
Oval filling defect
3
the hydro-dynamics were completely normal at a 4 D 6/7 D 6/7 Complete block
time when considerable neurological damage was 5 D 12/1 D 8/9 Complete block
6 D 8/9 D 8/9 Circular filling defect
present. The former patient went on to develop a 15 cm. diam.
Partial block
7 D 10/11 No calcification
total spinal block a year later and removal of the 8 D 12/1 No calcification Complete block
disc at that stage aggravated the paraplegia. 9 D 10/11 No calcification Complete block
10 D 8/9 D 8/9 _
Perhaps the important deduction from these D 9/10 _
_
D 10/11
findings is not that thoracic disc prolapse can D 11/12 Partial block
cause a complete spinal block but that in the early 11 D 9/10 D 9/10 Oval filling defect
2xl15 cm.
stages of the condition the manometrics and
cerebrospinal fluid may be entirely normal, and
even in the later stages of gross neurological disa- shows that in five of these eight patients the calci-
bility there may be at most a partial block or a fication occurred only in the nucleus pulposus of
slight increase in the protein content. the disc which had actually herniated. In two
other patients there were several calcified discs
Radiology.-In contrast to the clinical features (Cases 2 and 4 respectively) of which one in each
of prolapsed thoracic discs, which are of little value case corresponded to the site of the prolapse. In
in positive diagnosis, some of the radiographic the final case the calcification was present in a
changes form a reliable guide, and it should be single nucleus but this was situated four disc spaces
possible by this means to make a pre-operative above the protrusion. It would seem that nuclear
diagnosis in the majority of cases. calcification in the thoracic region is indicative of a
Arthritic lipping of the vertebral bodies in the degenerative change of such a nature as to render
thoracic spine, and often in the lumbar region as the disc liable to prolapse, but this change may also
well, is frequently seen in these patients but appears be present in other discs as yet uncalcified, and it
to be no more common or -more extensive than may happen that prolapse occurs from one of the
that observed in patients of this age group without latter.
disc prolapse. Narrowing of the affected disc was In a person suffering from spinal cord com-
not a constant feature and in fact was often seen in pression in the thoracic region calcification of a
discs which had not protruded. nucleus pulposus is an important finding, and as a
With regard to calcification of the nucleus general guide it may be stated that if the segmental
pulposus, however, it is an entirely different story. level of the lesion corresponds with a calcified

THORACIC DISC PROLAPSE WITH SPINAL CORD COMPRESSION
nucleus then the diagnosis of a protruded disc is
practically certain, and even when the segmental
level does not correspond a herniation is still the
most likely diagnosis.
The calcification is best seen in the lateral view.
Its appearance in the nucleus has no specific
features and, as Figs. 2, 3, and 4 demonstrate, it
varies considerably. It may consist of a uniformly
dense plaque which occupies part or the whole of
the nucleus (Fig. 2) or it may be arranged in the form
of flakes or granules (Figs. 3 and 4).
At operation the periphery of some of the pro-
trusions was found to be quite heavily calcified, but
it has been possible in only one (Case 6 and Fig. 5)
to demonstrate this circular rim by radiography.
In the others the shadow was presumably too faint
to be discerned amid the dense bone in the vicinity.
Myelography.-The thoracic region is notoriously
difficult to screen, partly owing to the superimposed
shadows of the heart and great vessels which tend to
obscure detail, and partly owing to the convexity of
this portion of the spinal column, which is accen-
tuated in these older patients. As soon as the
contrast material runs over the thoracic hump
whether going up or down the spinal canal it tends
to glide rapidly over the remaining vertebrae to gain
the lordosis of the lumbar or cervical regions, often
breaking up into globules as it does so, and during
this rapid flow it is possible to overlook the small
filling defects which may be the only sign of a
thoracic prolapse.
Table III shows that on myelographic screening
of these 11 cases four showed a complete block
which often had a convex border to it (Fig. 6 and
Case 9). Of the remaining seven, three revealed a
partial block without characteristic features and in
four the only evidence of a disc was a filling defect
'in the column of contrast material. This filling
defect has quite typical features (Fig. 7). It is
circular or oval in shape, varying from 1-5 to 2 cm.
in diameter, and overlies the intervertebral disc
space and adjacent portions of the vertebral bodies.
If good lateral views can be obtained (and this is
often very difficult) it is usually possible to demon-
strate that the obstruction lies anteriorly.
In two of the patients (Cases 3 and 8) in the
lateral view of the myelogram a " double profile "
could be seen at the level of the affected disc (Fig.
8), an appearance which depends on the prolapse
being situated to one side of the midline so that
part of the contrast medium runs over the convexity
of the prolapse and part runs in the dural gutter
alongside it, giving two levels which may be as
much as a centimetre apart.
B
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231
Mechanics of Spinal Cord Compression
It is pertinent at this stage to enquire briefly into
the means whereby the herniated disc produces
interference with cord function. In some cases
there is manifestly a true compression as a result
of the large size of the protrusion which may occupy
the greater part of the diameter of the spinal canal
and squeeze the cord backwards against the lamina
and ligamentum flavum. In other cases, however,
the prolapse may be relatively small and incapable
of " compressing " the cord as a whole, and another
explanation has to be sought. This problem has
previously arisen with regard to cervical disc lesions,
and two explanations have been put forward. One
concerns the ligamenta denticulata and the other
the blood supply to the spinal cord.
Kahn (1947) made the suggestion that the liga-
menta denticulata resisted the backward displace-
ment of the cord and produced traction on, and
distortion of, the nerve fibres in the vicinity of the
attachment of the ligaments to the transverse
meridian of the cord. This may well be the
explanation of the neurological signs in some of the
cervical disc compressions, particularly in those
Protected by copyright.
cases which present with almost exclusive involve-
ment of the pyramidal tracts.
In some cases of thoracic (and cervical) disc
compressions, however, it has been proposed that
interference with the blood supply is the basis of the
pathological change, in particular as a result of
obstruction or occlusion of the main arterial
trunk-the anterior spinal artery. This would best
explain (1) the appearance of a neurological picture
resembling that which occurs in known cases of
anterior spinal arterial thrombosis ; (2) the abrupt
onset in some patients of extensive damage to the
cord when at operation a hard prolapse evidently
of very long standing is found; (3) the occurrence
of degenerative changes amounting to necrosis of
the cord substance; and (4) the severe damage
inflicted on the cord out of all proportion to the
size of the protrusion, and the poor recovery that
may result despite the complete removal of. the
prolapse.
It was therefore with the hope that some light
would be thrown on this problem that the spinal
cord in the one patient coming to necropsy (Case 6)
was examined, but it was clearly shown in this case
that there were no demonstrable changes in the
main vessel which could be invoked as the cause of
the neurological picture or of the post-operative
transverse lesion.
The patient had a 14-month history of pro-
gressive paraplegia and developed a total transverse
 .:-

..........
.

Kb|i-#.?:Ga,~t/ FIGg.raph
FIG. 2.-Lateral radiograph of the thoracic spine in Case 10
showing the dense calcification in the nucleus pulposus
of three of the four calcified discs.

.'!:

West~~~~~~~~~~~~~~~~~~~rp

K|

FiG. 4.-Lateral radiograph of Case 6 showing the granular

appearance of the calcification in the nucleus of the
eighth-ninth intervertebral disc.
FIG. 3.-Lateral radiograph of Case 11 Flaky calcification
is present in the nucleus pulposus of the ninth-tenth
intervertebral disc.

\
~~~-~~t---~~)
|1_i~~~~~~~~~~~~~~~~~~~~~~~r . 5. A t

of
r

Cas
po

5.-Antero-posterior radio-
of Case 6 to show the
ing of calcification in the
wall of the prolapse from
~~~~~~~the
ninth-tenth intervertebral
disc.
te io

6t*hoh
radi

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Protected by copyright.
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IN

FiG. 6.-Myelogram of Case 9 illustrating the complete

obstruction just below the tenth-eleventh disc with a
convex lower border. It was similarly outlined from

Protected by copyright.
above.

lesion after operation, succumbing nine months

later. The spinal cord, dura, and prolapse were FIG. 7.-Myelogram of Case 11 showing the typical oval
filling defect at the level of the calcified disc (D 9/10).
removed in one piece and then sectioned en bloc
(Fig. 9). The extreme distortion of the fibre tracts
is well shown but the anterior spinal artery, although
in close apposition to the prolapse, is quite patent
without any thickening of its wall, and this appear-
ance was confirmed at higher and lower levels. The
anterior spinal vein also showed no evidence of
damage.
Surgical Results
The results of surgery in these cases are not such
as to foster complacency. There were in all five
bad results (Cases 2, 4, 5, 6, and 7) and two of these
patients died.
Of these five patients, three (Cases 5, 6, and 7),
all severely disabled before operation, developed a
total transection post-operatively. One (Case 5)
died four months later from urinary sepsis without
having made any neurological improvement. Case 6
showed slight recovery in motor power and pain
sensation and then died nine months after
operation from urinary sepsis and bed-sores. The
third patient (Case 7), who showed gross degenera-
tive changes in the spinal cord at operation, has
made no recovery in four years. The prolapse was
excised completely in the first case but in the other FIo. 8 Lateral radiograph of the myelogram in Case 3.
two surgical intervention was confined to a Calcification is present at the eighth-ninth and ninth-
decompression. tenth disc levels. The double profile of the contrast
medium outlines the prolapse which has occurred from
the upper less calcified, disc.
.:
.:e. w ;:
*c.:: S:c:*
*.:. .. .lys
*c
*...|;.::
^: :
t:.
1".
1.
*
Two patients (Cases 2 and 4), both showing
macroscopical degenerative changes in the cord
substance at operation, and the latter with a severe
pre-operative paraplegia, were rendered worse by
removal of the protrusion and then made slow,
incomplete recoveries over several years so that they
were eventually able to get about with the aid of
sticks. Six years after operation Case 4 again
retrogressed to an almost total paraplegia, possibly
from further protrusion of the disc.
Study of these five cases reveals that in addition to
their tragic outcome they had several other features
in common. The first of these was the severity of
the neurological disability before operation; and
four of these five patients had gross paraplegias at
the time of admission to hospital. The second
feature was the size of the compressing lesion, and
again four of these cases, out of five in the whole
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',
Protected by copyright.
the spinal cord, as manifested by the severity of the
neurological disability, the large size of the pro-
trusion, and visible degenerative changes.
The remaining six patients present a happier
picture.
Case 8.-This man had a severe paraplegia so that
he was able to walk only a few steps and then with
severe pain in the back and legs. Sensation was less
affected. Surgery was limited to a decompression as
the protrusion was of bony hardness. This procedure
seems to have arrested the progress of the condition
and there has been slight improvement in so far that
he is able to get about his house in reasonable comfort
and can walk distances up to 200 yards with a stick
and stand for periods up to half-an-hour. Sphincter
control is normal.
Case 1.-In this case there was evidence of a fairly
severe Brown-Sequard syndrome. Most of the disc
prolapse was excised; this temporarily exacerbated the

THORACIC DISC PROLAPSE WITH SPINAL CORD COMPRESSION
physical signs, but in the 12 months since operation
he has made steady improvement. He is now able to
walk distances up to two miles and has returned to work
driving a van. Bladder control is practically normal
and his original back pain, present for 10 years, has
disappeared.
Case 10.-This patient was grossly disabled and was
unable to lift his legs against gravity. There was dense
sensory loss and retention of urine and faeces. A
complete removal of the prolapse was carried out. It
is now two and a half years since operation. He is
able to walk 500 yards with the aid of sticks and has
returned to full-time sedentary work. Some urgency
of micturition persists but bowel control is normal.
Case 11.-This man had a similar but slightly less
severe neurological deficit. The major part of this
prolapse was removed but the right hand margin was
inaccessible. It is now three and a half years since
operation and for the last two and a half he has been
back at full work and can walk and run normally, and
drives a car. His only residual symptom is that of a
sensation of cramp and tightness in the muscles of the
left leg and subjective numbness of the feet.
Case 9.-This patient showed considerable motor
weakness with milder posterior column sensory impair-
ment as a result of an acute prolapse of softened nucleus
pulposus, which was completely excised. At 10 months
after operation he can walk any distance with one stick.
He has no pain or sensory change and sphincter control
is normal.
Case 3.-This was the youngest patient in the series
and presented with a mild Brown-Sequard syndrome.
The disc was totally excised. It is now three years since
operation and for the last two and a half of them he has
been back at full work, and can walk, run, dance,
and dig as well as he ever did. His remaining symptoms
are those of a sensation of tightness in the calves and
some loss of potency.
This last case represents the best result obtained in
this series and is perhaps accounted for by the short
history of compression (two and a half months), a
small prolapse, and the absence of degenerative change
in the cord at operation.
Surgical Management
The surgery of compressing lesions which lie
anterior to the spinal cord is never easy and is made
immeasurably more difficult in disc prolapse by the
changes produced in the cord which render it
vulnerable even to the slightest surgical trauma.
In addition the anatomical relationship of the cord
to the protrusion (Fig. 9) makes access extremely
difficult. The consistency of the prolapse is some-
times another hazard, for it may be composed of a
small central area of cartilage set between bony
spurs which project from the vertebrae above and
below (Case 7), and which cannot be chiselled away
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235
without risk of further injury to the nervous struc-
tures. However, a recent report by Allen (1952)
suggests that it is possible to remove these spurs
by the technique he describes without increasing
the damage to the cord, and it may be that a more
radical attitude will be taken in the future.
In the surgical approach the most important
factor is an accurate pre-operative diagnosis and the
knowledge from the start that one is dealing with a
discal hernia. This knowledge should ensure
removal of the lamina with the utmost caution and
so prevent any further compression of the cord
against the unyielding prolapse during the exposure.
Other technical points are: that the laminectomy
should be extensive consisting of at least three,
preferably four, laminae; in a narrow spinal canal
I have no hesitation in removing the pedicle on the
side of the maximum protrusion to gain a more
lateral approach; all the ligamenta denticulata
in the operative field should be divided. It is
perhaps hardly necessary to emphasize the extreme
gentleness required in lifting up the edge of the
spinal cord to gain access to the hernia, and for this
reason it is best to remove the prolapse by the
Protected by copyright.
intradural route so that the minimal displacement
of the cord that is permitted can be kept under
direct control. The soft central area of the prolapse
is usually easily removed but the hard rim may
require to be excised piecemeal with a fine gouge.
Once the protrusion has been exposed a decision
has to be made either to attempt its removal or to be
content with a decompression with or without
division of the ligamenta denticulata. If there is an
area of necrosis in the cord, and this is a most
ominous sign even when the associated neurological
deficit is not severe (Case 2), a decompression is all
that should be done. If the type of prolapse is that
of the transverse bony spur it is again probably
safer not to attempt a radical excision (but this view
may require modification in the future). On the
other hand, if the cord is not grossly abnormal and
the prolapse has the more usual rounded, some-
times mushroom, shape it is imperative to remove it
entirely for it is only by this means that any con-
siderable recovery in neurological function can
result.
It is evident that the reputation these central
thoracic disc protrusions have acquired is not
undeserved. It is only by early diagnosis before
permanent changes occur in the spinal cord that an
improvement in surgical results will be obtained,
and this should be possible, if with a progressive
thoracic spinal lesion the significance of a calcified
nucleus pulposus is appreciated, and myelography
with careful screening is undertaken at a stage when
 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.15.4.227 on 1 November 1952. Downloaded from http://jnnp.bmj.com/ on August 5, 2022 by guest.
236 VALENTINE LOGUE
the manometrics and cerebrospinal fluid may well light touch in the left leg. After 10 days the bladder
be normal. recovered and power and sensation improved.
Case Histories At one year after operation the patient can walk two
miles with a stick and has returned to full work driving
The post-operative condition of the 11 patients is a van. Bladder control is practically normal. The
described mainly in terms of recovery of function original back pain has gone. Improvement still
and the finer details of neurological examination continues.
are omitted.
The first three cases are examples of incomplete Case 2.-A man aged 44, a van driver, six months
before admission developed a sensation of coldness and
Brown-Sequard syndromes. numbness on the outer side of the left leg below the
Case 1.-A man aged 48, a greengrocer, four months knee, which had persisted but not extended. There
before admission developed numb feeling in both legs had been weakness and stiffness of the right leg and
followed in a few days by weakness, particularly in the similar changes in the left leg for six weeks, but no pain,
left leg, which progressed steadily. He had no sphincter no sphincter disturbance, and no spinal injury.
disturbance. Ten years previously, after lifting a heavy Neurological Examination.-There was moderate
weight pain appeared in the upper lumbar region and generalized weakness in the right leg and increased tone,
had occurred intermittently ever since. It had an with ankle and patella clonus. In the left leg power,
aching character, did not radiate, and was not severe, tone, and coordination were normal.
usually being relieved by the application of heat. He Abdominal reflexes were absent. The right knee and
had also contracted syphilis 21 years previously for which ankle jerk were exaggerated. The left deep reflexes
he had received treatment at the time. were normal. The plantar responses were extensor.
Neurological Examination.-There was generalized Sensory change was confined to diminution of pain
weakness of the left leg with increased tone but no sense on the outer side of the left leg from knee to
clonus, and impaired coordination. ankle. All other modalities were normal.
Reflexes were exaggerated with an extensor plantar Radiography.-Arthritic lipping of the bodies of most

Protected by copyright.
response. In the right leg no abnormality of power, thoracic vertebrae was seen, and spotty calcification in
tone, or reflexes was discerned. the anterior portion of the nucleus pulposus of the
On the left side sensation was normal except for the eighth-ninth disc with narrowing of the disc space.
absence of vibration sense over the tibia. On the
right there was a sharply defined level at the twelfth Myelography (Cisternal).-Contrast was partially
thoracic dermatome below which there was impairment arrested just above the eighth-ninth disc.
of pain, temperature, and light touch. Vibration sense Lumbar Puncture.-This showed normal manometrics.
was normal. The sense of position and passive move- Protein was not recorded.
ment was unaffected in both legs.
The patient could walk unaided, rather hesitantly, Operation.-Laminectomy of the seventh, eighth, and
circumducting the left leg. ninth vertebrae was performed. A firm swelling was
felt through the dura at D.8 level. The cord was
Radiography.-Radiography showed dense mottled bulged backwards by a small tense prolapse from the
calcification of the ninth-tenth nucleus pulposus without eighth-ninth disc. Just to the right of the midline at
narrowing of the disc space and arthritic lipping of the convexity of the bulge there was an area in the cord
D.l1 and 12. substance, 3 mm. in diameter, which had a blue, trans-
Myelography.-Myelography showed an oval filling lucent appearance. On incision of the prolapse soft,
defect 2 by 1.5 cm. at the level of the calcified disc. yellow tissue extruded. A complete intradural removal
Lumbar Puncture.-Manometrics were normal. The was effected.
fluid contained one cell per c.mm. and 55 mg. of Post-operative Course.-The patient had a complete
protein per 100 ml. The Wassermann reaction was flaccid paralysis of both legs. Below the eleventh
negative, and the Lange reaction unchanged. thoracic dermatome all sensation was absent on the
Operation.-Laminectomy of the ninth, tenth, and right but diminished. on the left pain and light touch could be felt
eleventh thoracic vertebrae was performed. A firm although Urine and faeces were retained.
Movement began to return in the feet in one month and
swelling was felt anteriorly through the dura. The there was slow recovery for 18 months after which his
spinal cord was kinked backwards by a hard swelling condition
indenting the dura anteriorly, and was pale with some (11 years). hasHeremained stationary to the present time
can stand, but with flexion of all joints,
venous congestion. The dura and capsule of the and can walk slowly with two sticks. He has dribbling
prolapse were incised and soft, stringy disc tissue extruded. incontinence and wears a rubber urinal all day and has
Complete removal, partly intra- and partly extra-dural, a bottle in bed at night. The bowels act every fourth
was effected. day with aperients. There is extreme spasticity of both
Post-operative Course.-The patient developed reten- legs with clonus and exaggerated reflexes and extensor
tion of urine and impairment of pain, temperature, and plantar responses. Flexor spasms occur on the slightest

THORACIC DISC PROLAPSE WITH SPINAL CORD COMPRESSION
stimulus. There is a level at the eleventh thoracic
dermatome below which pin prick is impaired and ther-
mal sensation is absent. Light touch is well appreciated.
Joint sense is reduced in the toes.
Case 3.-A man aged 38, a business executive, nine
months before admission, a few days after some heavy
work in his garden, developed an aching sensation to
the left of the midline of the back at about the dorsi-
lumbar junction, and this ache had persisted. For two
and a half months he had been unsteady on his feet and
for the same time the right lower limb had been numb
from the hip downwards, most evident on the lateral
aspect of the leg and foot, with a tingling sensation in
the toes of both feet. There was no sphincter distur-
bance.
Neurological Examinationt.-Slight weakness of both
legs was detected predominating in the left and more
marked peripherally, with increased tone, ankle and
patella clonus on the left and patella clonus on the right.
The knee and ankle jerks were very brisk, particularly
on the left, and the plantar responses were extensor.
Sensory change was confined to the right side. Below
the twelfth thoracic dermatome there was impairment
of pain and temperature with sparing of sacral segments.
Light touch was normal. Vibration sense was absent
at both malleoli. Joint and position sense was unaf-
fected.
Radiography.-Calcification in the nucleus pulposus
of both the eighth-ninth and ninth-tenth discs was
seen, more extensive in the latter, with slight narrowing
of the eighth-ninth disc.
Myelography.-Myelography showed an oval filling
defect at the eighth-ninth disc level. In the lateral
views a " double profile (Fig. 8) was seen.
"
Lumbar Puncture.-Manometrics showed a partial
block with a " sticky " rise and fall to 250 mm. H20.
The fluid contained 1 cell per c.mm. and 30 mg. of
protein per 100 ml.
Operationi.-Complete laminectomy of the eighth and
ninth vertebrae was performed. A hard swelling was
felt anteriorly. The spinal cord was displaced back-
wards by a spherical protrusion from the eighth-ninth
disc lying mainly to the left of the midline. The spinal
cord substance appeared normal. On incision through
the dura and capsule soft, degenerate cartilage extruded.
The harder rim was removed piecemeal.
Post-operative Course.-The legs were much weaker
for a few days, but after that there was steady improve-
ment. At three years after operation the patient can
walk, run, dance, and dig as well as ever. Sensation is
normal. His remaining symptoms are those of tightness
in the calf muscles and some loss of potency.
Case 4.-A man aged 52, an insurance broker, two
years before admission developed numbness in the left
big toe which spread up the leg within a few months.
Six months after the onset a similar change appeared in
the right leg associated with weakness of this leg. After
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237
a further six months weakness started in the left leg.
Both the motor and sensory loss progressed relentlessly
so that at three months before admission a stage was
reached where he was numb from the costal margin
downwards and could take only a few faltering steps
with support. Flexor spasms had been present for 12
months. Rectal control was normal, as was the initia-
tion of micturition but he had difficulty in knowing
when the bladder was empty. There had been no pain
at any time. Six months after the onset of symptoms
he had been investigated elsewhere when the cerebro-
spinal fluid and manometrics revealed no abnormality
and a myelogram did not show a block.
Neurological Examiniation.-Some loss of power in
the abdominal muscles with gross loss in both legs was
perceived but a small range of movement was possible
at all joints. Tone was increased without clonus.
The abdominal reflexes were absent. The knee and
ankle jerks were exaggerated on the left, normal on the
right. Plantar responses were both extensor.
There was a level at the sixth thoracic dermatome
below which pain was considerably impaired and
temperature sense was lost. From the sixth to the
tenth dermatome the skin was hyperaesthetic to light
touch and below this hypoaesthetic. These sensory
changes extended down to cover the whole of the right
leg but on the left leg there was relative sparing below
Protected by copyright.
the third lumbar dermatome. Position sense was
reduced at the toes. Vibration sense was diminished at
all bony points in the legs.
Radiography.-Mottled calcification was seen in the
nucleus of the sixth-seventh disc.
Cistern2al Myeloglram.-This showed a complete block
just above the area of calcification.
Lumbar Puncture.-A complete block was demon-
strated. The fluid was yellow with increased protein
(precise amount not recorded).
Oper-ationi.-Laminectomy of the fifth, sixth, and
seventh thoracic vertebrae was performed. A hard
swelling was palpable anteriorly. The spinal cord was
angled backwards by a smooth disc prolapse occupying
two-thirds of the diameter of the spinal canal. In the
cord substance there was an area, in. long and 4- in.
wide, of a dark purple lying just to the left of the midline.
On incision of the dura and capsule yellow degenerate
disc tissue extruded. Its hard rim was completely
removed intradurally. A few drops of yellow fluid were
aspirated from the discolored area of the cord.
Post-operative Course.-The patient had almost
complete motor and sensory paralysis, with retention.
A few degrees of movement remained in the toes and
there was patchy retention of light touch over both legs.
Recovery in motor power started six weeks later and
continued slowly so that he could walk with sticks at
11 months. Maximum recovery was attained four
years after operation when he could walk with one
stick for 15 minutes, could drive a car, and had control
of the bowel and bladder although some urgency of
micturition persisted. At six years a further deterio-

238 VALENTINE LOGUE
ration set in, the legs became too weak to support him
and he has remained bed-ridden to the present time
(13 years after operation).
Case 5.-A man aged 62, an estate manager, three
weeks before admission suddenly developed severe pain
in the lumbar region radiating down both legs;
it was particularly bad in the front of the thighs.
He continued to work for five days when numbness
appeared in the soles of both feet and spread rapidly
up the legs and at the same time the legs became weak
and his balance unsteady. There was no sphincter
disturbance and no history of spinal injury.
Neurological Examination.-There was considerable
weakness of the legs, more marked in the right, so that
he was unable to lift them off the bed. One inch
wasting of the right thigh and fibrillation in both calves,
with general loss of tone, was also seen.
Knee jerks were diminished, ankle jerks absent, and
plantar responses extensor.
Sensory change was confined to the antero-lateral
aspects of both legs (fourth lumbar dermatome) where
pain, temperature, and light touch were diminished.
Joint sense was reduced in toes and ankles.
Radiography.-Considerable arthritic lipping of the
lower six thoracic vertebrae was shown. There was
dense calcification in the nucleus of the eighth-ninth
disc with a thin plaque of calcification in the arachnoid,
1 cm. long by 1 mm. thick, at the level of the first lumbar
vertebra.
Myelography.-A complete block at D.12/L.1 disc
was seen.
Lumbar Puncture.-This showed an absolute mano-
metric block. The fluid was yellow containing 7 cells
per c.mm. and 175 mg. of protein per 100 ml.
Operation.-Laminectomy of the twelfth thoracic and
first lumbar vertebrae was performed. The spinal cord
was pushed over to the right by a large prolapse from
the 12/1 disc. The protrusion was exposed extra-
durally and, surprisingly, in view of the short history,
was found to be of an extremely hard consistency and
had to be cut away piecemeal. The calcified arach-
noidal plaque was also removed.
Post-operative Course.-The patient had total motor
and sensory paraplegia below the level of the second
lumbar segment. He died four months later in another
hospital from pyelonephritis without any recovery taking
place. No necropsy was obtained.
Case 6.-A woman aged 44, a housewife, 14 months
before admission found that her legs suddenly gave way
and on picking herself up she realized that they were
weak. The weakness progressed steadily after this,
more marked in the right leg, and walking became
difficult and she often fell. For six weeks before
admission she could only go about by clinging on to
fumiture for support. At some time during these 14
months numbness had appeared in the legs but she
could not give the precise time. She had no sphincter
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disturbance, no pain at any time, and no history of
injury.
Neurological Examination.-There was considerable
generalized weakness of both legs, more marked in the
right, with increased tone and ankle and patella clonus.
The lower abdominal reflexes were absent, the knee
and ankle jerks exaggerated, and plantar responses
extensor.
There was a well-defined level at the eighth thoracic
dermatome below which there was reduced sensation
to pain and temperature, and from the eleventh derma-
tome downwards there was analgesia and thermo-
aesthesia. There was only vague and patchy loss to
light touch. Joint sense was absent at the toes. Vibra-
tion sense was absent up to and including the iliac crests.
Radiography.-Granular calcification in the nucleus
of the eighth-ninth disc without narrowing (Fig. 4) was
seen. In the antero-posterior view a faint circular rim
of calcification, 15 cm. in diameter, was visible in the
spinal canal overlying the calcified disc (Fig. 5). It
could not be seen in the lateral view.
Myelography.-A circular filling defect, 15 cm. in
diameter, was seen at the calcified disc level and out-
lining the circular opacity.
Lumbar Puncture.-A complete manometric block was
shown. The fluid was clear, containing 2 cells per c.mm.
Protected by copyright.
and 95 mg. of protein per 100 ml.
Operation.-Laminectomy o the eighth and ninth
thdracic vertebrae was performed. A hard swelling
was felt anteriorly in the dural sac. The cord was
kinked backwards by a prolapse from the eighth-ninth
disc. Owing to the firm consistency of the prolapse it
was not removed. Two ligamenta denticulata were
divided and the dura left open.
Post-operative Course.-There was total transection
below the eighth thoracic segment. At six months a
few degrees of movement had returned in the left ankle
and knee and in the right ankle with a little recovery of
pain sense below the right knee with hyperpathia. The
legs were extremely spastic with frequent flexor spasms.
The patient had recurring attacks of urinary sepsis and
developed bed sores. She eventually died nine months
after operation.
At necropsy the prolapse, cord, and dura were
removed in one piece and sectioned (Fig. 9).
Case 7.-A woman aged 63, a housewife, 10 years
before admission twisted her spine suddenly and the
following day she found she was unsteady on her feet
tending to veer to the left. A week later on getting into
a bath she observed that she could not appreciate
temperature in the skin below the knee on the right, and
urgency of micturition developed. Two years later
both legs became stiff and weak, more marked in the
right, but the bladder symptoms had cleared up. During
the last six years preceding admission the weakness and
stiffness progressed so that she could get about only by
holding on to the furniture, and both legs felt numb.
For one year the legs were much weaker and she could

THORACIC DISC PROLAPSE WITH SPINAL CORD COMPRESSION
just stand with support. Flexor spasms occurred
frequently. Urgency of micturition had reappeared
with occasional incontinence. There had been no pain
at any time.
Neurological Examitiationi.-There was extreme weak-
ness of both legs with a small range of movement re-
tained at all joints, and gross spasticity with ankle and
patella clonus.
The abdominal reflexes were absent, the knee and
ankle jerks exaggerated, with bilateral extensor plantar
responses.
Sensation was difficult to define, but repeated testing
indicated some reduction of pain, temperature, and
light touch below the second lumbar dermatome on the
right and the third dermatome on the left. Vibration
sense was absent in the tibiae and patellae. Joint sense
was unaffected.
Radiography-.There was gross arthritic lipping of all
thoracic vertebrae. No calcification was seen.
Myelography.-Myelograms showed a partial block
at the level of the tenth-eleventh intervertebral disc,
with a convex lower border.
Lumbar Punicture.-This demonstrated a complete
manometric block. The fluid was clear, containing 3
cells per c.mm. and 150 mg. of protein per 100 ml.
Operationi.-Laminectomy of the tenth, eleventh, and
twelfth vertebrae was performed. A hard lump was
palpable. The cord was bulged backwards and was of
paper thinness and for almost a centimetre of its length
had a translucent blue discoloration. The prolapse
was an extremely hard bar extending across the spinal
canal containing a small amount of soft cartilage set
between bony spurs. The ligamenta denticulata were
divided above and below but no attempt was made to
remove the disc prolapse.
Post-operative Coui-se.-Paraplegia below the first
lumbar spinal segment was complete. It is now four
years since operation and there has been no recovery in
power or sensation. There is some return of tone in
the legs and the patient is able to get about in callipers
and crutches. By emptying the bladder every three
hours she remains dry.
Case 8.-A man aged 54, a charge hand, 11 weeks
before admission suddenly developed severe pain in
the lumbar region which radiated down his legs both
back and front to the feet. Sharp exacerbations occurred
on coughing, sneezing, and straining. He remained in
bed for six days and then on getting up found his legs
were very weak. This weakness progressed rapidly so
that within another few days his legs would not support
him. At the same time a burning sensation appeared
in the lateral toes of both feet which spread to involve
the front of the legs below the knees and within a few
days was replaced by numbness. Urgency of micturition
appeared at the start of symptoms but cleared up within
a few weeks. He was admitted to another hospital five
weeks after the onset where after an initial slight improve-
ment his condition remained stationary.
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239
Neurological Examination.-There was considerable
generalized loss of power in both legs, more marked in
the right. Tone was increased with ankle clonus.
The abdominal reflexes were absent, the knee and
ankle jerks exaggerated, and plantar responses extensor.
Cutaneous sensory change was confined to an area on
the anterior aspects of both shins (corresponding to
the fourth lumbar dermatome) where there was reduction
of pain, temperature, and light touch. Position sense
was impaired in the toes. Vibration sense was reduced
in the left tibia.
He could walk without support but unsteadily, on a
broad, shuffling base, with considerable pain.
Radiography.-Gross arthritic lipping of most of the
thoracic and all the lumbar vertebrae was seen, but no
calcification.
Myelography.-Myelograms showed complete block
at the level of the intervertebral disc between D12/Ll
vertebrae. The obstruction was outlined from above and
below and was found to be 1-5 cm. long and to have a
rounded outline.
Lumbar Puncture.-Almost complete manometric
block was shown. The fluid contained 2 cells per
c.mm. and 200 mg. of protein per 100 ml.
Operation.-Laminectomy of the twelfth thoracic and
first lumbar vertebrae was performed. A firm knob
Protected by copyright.
was felt anteriorly in the theca. The cord was bulged
backwards and was pinker than usual. Anterior to it
was a large and extremely hard prolapse from the 12/1
disc. Its hardness was surprising in view of the short
history. No attempt was made to remove it and the
patient was left with a decompression.
Post-operative Course.-The paraplegia was made
worse and retention of urine developed. After 10 days
improvement started and within a few weeks he regained
his pre-operative level. The cutaneous sensory change
cleared up.
Two and a half years after operation he can get about
his house and garden and can walk distances up to 200
yards. He can stand for periods up to half an hour
before aching in the legs becomes severe. Sphincter
control is normal. The operation seems to have
arrested the progress of the condition and there has
been a little improvement in movement compared with
his pre-operative state.
Case 9.-A man aged 61, a labourer, 13 days before
admission, while putting on his overcoat, suddenly
developed severe pain in the midline of the lumbar
region and at the same time his legs became weak. He
retired to bed and on attempting to get up two days
later he found his legs would not support him. He had
observed no sensory or sphincter disturbance, and there
was no history of spinal injury.
Neurological Examination.-There was generalized
weakness of both legs, more marked in the right, and
increased tone with patella clonus. Coordination was
grossly impaired.
Both knee jerks were exaggerated, the ankle jerks
brisk. Plantar responses were extensor.

240 VALENTINE LOGUE
There was vague loss of sensation to pin prick below
mid-thighs which cleared up within a few days. Tem-
perature and light touch were unaffected. Position
sense was considerably reduced at the toes and ankles
and vibration sense was absent in the tibiae.
Radiography.-There was arthritic lipping of the lower
thoracic and all the lumbar vertebrae, but no calcification
or disc narrowing.
Myelography.-A circular lesion causing a complete
block was outlined from above and below over the
tenth-eleventh intervertebral disc (Fig. 6). In the
lateral view a suggestion of a " double profile " could be
seen.
Lumbar Puncture.-A partial block was shown. The
fluid contained 4 cells per c.mm. and 100 mg. of protein
per 100 ml.
Operation.-Laminectomy of the tenth, eleventh, and
twelfth thoracic vertebrae was performed. A firm mass
could be felt anteriorly in the theca. The cord was
kinked backwards and a little swollen but not dis-
coloured. A tense swelling could be seen arising from
the 10/II disc lying to the left of the midline. It was
approached extradurally and found to be the size of a
pea and composed of soft degenerate disc tissue id6htical
with the common lumbar protrusions. It was removed
completely.
Post-operative Course.-After a transient exacerbation
of signs power increased considerably in the legs with
disappearance of spasticity and clonus and he could
walk with support. Joint sense returned to normal
within a fortnight. Now, 10 months after operation, he
is able to walk any distance with one stick and his only
complaint is of a little unsteadiness on his feet. There
is no pain or sensory disturbance and sphincter control
is normal.
Case 10.-A man aged 44, an engineer, five months
before admission developed difficulty in starting mic-
turition and had to strain to empty his bladder. This
symptom cleared up in a fortnight. Two weeks later
stiffness and weakness of the left leg appeared and after
a further month the right leg was similarly affected.
The weakness in both legs progressed steadily so that
for the month before admission he had been unable to
walk and had also become incontinent of urine and
faeces. A sensation of coldness behind both knees
appeared at the inception of his symptoms and remained
stationary until the last few weeks when numbness of the
skin below the umbilicus was noticed and which rapidly
spread down to involve both legs. For one week there
had been frequent flexor spasms. There was no com-
plaint of pain at any time.
Neurological Examination.-Some weakness of the
lower abdominal muscles with gross reduction of power
in both legs was perceived so that the patient was unable
to lift them off the bed, but a small range of movement
was retained at all joints. Tone was increased with
clonus at the left ankle. The lower abdominal reflexes
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were absent, the knee and ankle jerks exaggerated,
the plantar responses extensor.
There was a level at the eleventh thoracic dermatome
on the right and the twelfth on the left below which pain,
temperature, and light touch were impaired but not
lost. Position sense was absent at the toes, ankles, and
knees, and reduced at the hip joints. Vibration sense
was lost below the third lumbar spinous process.
Radiography.-Arthritic lipping of the lower three
thoracic vertebrae was visible. Calcification of the
nucleus pulposus was present in the four intervertebral
discs between the 8/9, 9/10, 10/11, and 11/12 vertebrae
(Fig. 2).
Myelography.-There was no block discernible on
running the contrast up to the cervical region, but in the
reverse direction there was a transient arrest at the 6,7
disc and again at the 8/9.
Lumbar Puncture.-Partial block was shown. The
cerebrospinal fluid was clear and contained 2 cells per
c.mm. and 20 mg. of protein per 100 ml.
Operation.-Laminectomy of the seventh to the tenth
vertebrae inclusive was performed to expose both levels
which the myelogram had shown to be abnormal. The
protrusion was found at the lower, 9/10 level (there was
no abnormality discovered at the 6/7 disc). The cord
was paler than normal and had fewer blood vessels on
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its surface. It was kinked back by a protrusion the size
of a pea lying slightly to the left of the midline. The
centre of the prolapse was soft but its wall was very
hard and calcified, and it appeared that the protrusion
had been present for a much longer time than the
symptoms suggested. Its contents were removed and
then the rim excised piecemeal with a small scoop.
Post-operative Course.-Transient worsening of physi-
cal signs for a few days was followed by steady if slow
improvement. Within two weeks the patient could lift
his legs off the bed and had regained bladder control.
The sensory and reflex changes persisted. Two and a
half years after operation he can walk up to 500 yards
with two sticks and can climb stairs slowly. He has
recently returned to sedentary work. He still has some
urgency of micturition.
Case 11.-A man aged 45, a research chemist, whose
clinical features have been described on a previous page.
Radiology.-Calcification was present in the nucleus
pulposus of the ninth-tenth disc, without any narrowing
(Fig. 3).
Myelography.-Myelograms showed an oval filling
defect at the level of the calcification measuring 1, cm.
in diameter (Fig. 7).
Lumbar Puncture.-Manometrics were normal. The
cerebrospinal fluid contained 4 cells per c.mm. and 50
mg. of protein per 100 ml.
Operation.-In view of the discrepancy between the
clinical and radiological levels it was thought there
might be two lesions and that both should be explored.

THORACIC DISC PROLAPSE WITH SPINAL CORD COMPRESSION
The upper level was exposed first and revealed no
abnormality. A laminectomy of the ninth and tenth
vertebrae was performed and a firm swelling could be
felt in the dural sac On opening the theca the cord was
seen to be displaced backwards by a prolapsed disc.
The protrusion arose by a narrow neck and then ex-
panded into a spherical mass about 1L! cm. across with
the dura and cord stretched over its surface. There was
no discoloration of the cord substance. The rim of
the disc was hard and partly calcified but its contents
were soft, degenerate cartilage. As a result of the
intimate relationship to the cord it was extremely
difficult to remove all the calcified rim and its right-hand
margin had to be left in situ.
Post-operative Course.-Physical signs were made
considerably worse and the bladder required tidal
drainage. Improvement started after 10 days. By the
time of discharge from hospital five weeks later power
had improved so that the patient could walk without
assistance although unsteadily. By four months after
operation he was walking normally.
Three and a half years after operation he walks, runs,
swims, and drives a car. All modalities of sensation
are normal except for subjective numbness of the feet.
The right knee jerk is still brisk but plantar responses
are flexor. His only complaint is that of a sensation of
tightness in the calf muscles.
Summary
Attention is drawn to the serious damage inflicted
on the spinal cord by central thoracic disc pro-
trusions. Eleven cases are described and it is
shown that this type of prolapse is confined to the
lower nine disc spaces without any particular level
predominating. It is commoner in men of middle
and late adult life and has little relationship to
trauma.
The clinical features are not characteristic and are
those of a fairly rapidly progressive spinal com-
pression, so that in eight of the patients a severe
neurological disability leading to operation was
present within seven months from the onset of
symptoms. Three cases presented with incomplete
Brown-Sequard syndromes. Pain was an infrequent
J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.15.4.227 on 1 November 1952. Downloaded from http://jnnp.bmj.com/ on August 5, 2022 by guest.
241
symptom. Sphincter disturbance occurred late and
was present in less than half the cases.
Five patients showed a manometric spinal block
with high protein but the important feature was the
number of patients with only a slight rise of
protein or little evidence of block. X-ray changes
formed the important diagnostic guide. Eight
showed calcification of the nucleus pulposus. The
typical myelographic appearance was an oval filling
defect.
The dangers associated with visible degenerative
changes in the cord are emphasized.
The pathological basis of interference with cord
function produced by the small protrusions is
discussed.
Operation results are reviewed. Three patients
developed total transections post-operatively and
two of them died. Two other patients were made
worse by surgery and made slow, incomplete
recoveries. Six patients did well, five of them
returned to work, and in three the improvement
was of a grade similar to that following removal of
benign spinal neoplasms such as meningiomata or
neurofibromata. Some details of surgical technique
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are stressed.
It is a pleasure to express my indebtedness to my
senior colleague Mr. Wylie McKissock for permission
to include six of his patients in this series; to Professor
T. Crawford for the preparation of the necropsy specimen
in Case 6 and the photomicrographs of the sections,
and to Dr. James Bull for many of the radiographs
and myelograms.
REFERENCES
Allen, K. Lewer (1952). Journal of Neurology, Neurosurgery and
Psychiatry, 15, 20.
Bradford, F. K., and Spurling, R. G. (1945). The Intervertebral
Disc, 2nd ed. Springfield, Ill.
Elsberg, C. A. (1931). Bull. neurol. Iist. N. Y., 1, 350.
Hawk, W. A. (1936). Brain, 59, 204.
Kahn, E. A. (1947). J. Neurosurg., 4, 191.
Love, J. G., and Kiefer, E. J. (1950). Ibid., 7, 62.
Mixter, W. J., and Barr, J. S. (1934). New Engl. J. Med., 211, 210.
Muller, R. (1951). Acta med., scand., 139, 99.
Stookey, B. (1928). Arch. Neurol. Psychiat., Chicago, 20, 275.